Notes on the article:
They present the “multifidus triangle syndrome”. This paper presents a low back pain syndrome in the same area as the back mice and cluneal nerve entrapment occur.
The syndrome is related to RECURRENT Low Back Pain to the lower portion of the MULTIFIDUS muscle.
They do not mention any palpable nodules; instead they mention a LOCAL DEEP TENDER AREA. They treat the affection by local anesthetic injection.
Bauwens and Coyer do not comment on the possible etiopathogenic factors. They DO NOT make any hypothesis of the cause of pain or why the local injection would work. They just focus on the pain management.
The authors treat 20 patients with local injection with cortisone, local anesthetic and hyaluronidase with good outcomes. The treatment seems to work for the “multifidus triangle syndrome” as it works with the “back mice“.
by Philippe Bauwens and Anthony B. Coyer.
Department of physical medicine, St. Thomas’ Hospital. England
The identification of a pattern:
The authors had identified a similar pattern of history, signs and symptoms from the patients who were attended in the Physical Medicine Department from St. Thomas Hospital.
The pattern suggested that the CAUSE was a lesion in the SOFT TISSUES occupying a triangular zone on either side of the posterior surface of the sacral area.
Bauwens and Collée comment on previous work from Livingston related to low back pain
In 1941 Livingston described this syndrome in the area named “multifidus triangle” because in it lays the lowest end of the multifidus muscle.
The function of this muscle is to stabilize the spine in its relation to the sacrum.
Livingtson related the pain to physical exercise involving bending and twisting. A sharp localized pain can be followed by a persistent discomfort ascribed to one spot just below the posterior superior iliac spine. The ache may gradually decrease during the following days. And then the pain recurs after intervals of relative freedom from pain.
They also comment about previous work from Steindler and Luck
In 1938 Steindler and Luck published a study from 451 patients suffering from low back pain. They observed that in more than 20% of these cases it was possible to demonstrate a LOCAL POINT OF TENDERNESS situated in the deeper tissues. They conclude that the lesions were a ligamentous injury or myofascial lesions.
The work of Lewis and Kellgren (1939) suggests that such a focus may result in both deep and superficial tenderness, and radiation of pain to buttocks and thighs with or without muscle spasm. In 1943 Livingston treated such cases with several local injections of 2% procaine solution into the sensitive “trigger points”, and obtained eventual relief after several injections.
Bauwens et al. performed combined local injection with cortisone, hyaluronidase and anesthetic to treat low back pain
They hypothesized that the injection of procaine with hydrocortisone and hyaluronidase would give a quicker and more durable effect.
Bauwens et al. selection of low back pain cases
All the patients selected were carefully examined, also with X-rays (that revealed nothing abnromal except “osteophytic lipping” in some older patients).
- the site of the pain
- whether there was radiation
- whether there was limitation of movements
- neurological signs
Bauwens et al. results from 20 patients with low back pain that they considered as “multifidus triangle syndrome”
- 20 patients (14 women)
- Main complaint: dull pain localized in lumbar area
- intermittent character
- worse with excessive bending or lifting
- occasionally radiated to the buttock
- relief on resting in bed
- 10 had past history of trauma that they related to the start of the trouble
- Physical examination showed pain on the back extension
- On palpation, LOCALIZED TENDERNESS was found in the multifidus triangle
- Straight-leg rising was full and complete in all cases
- Pain from 2 years to one month, mainly intermittent in character
INJECTION technique in the “multifidus triangle syndrome”
-In each case the point of maximum tenderness was located in the “multifidus triangle” with patient lying in the prone position.
-They marked the spot with a skin pencil.
-They injected a mixture of: 50 mg hydrocortisone in a 2ml suspension + 1,000 units of hyaluronidase and 4 ml of 1% procaine hydrochloride.
-The patient usually complained of increased pain and radiation as the tender focus was irritated by the needle.
-The patient was allowed to rest for 15 minutes and then re-examined again.
-Every case showed improvement despite most still referred slight dull ache.
-All the cases were re-examined every week for one month.
-15 were free of pain the first week.
-2 required a second injection because of residual pain.
-At the end of the 4 weeks all were free of pain. For a period of six months there have been no recurrences.
Images from the MULTIFIDUS muscle
Published in June 2018 By Marta Cañis Parera
- BAUWENS P, COYER AB. The multifidus triangle syndrome as a cause of recurrent low-back pain. Br Med J. 1955 Nov 26;2(4951):1306-7. PubMed PMID: 13269857
- Livingston W.K. 1941. West. J. Surg. 49, 259.
- Steindler A and Luck J.V. 1938. J. Amer. Med. Ass. 110, 106.